Premenopausal abnormal uterine bleeding
Normal menstrual bleeding lasts an average of 5 days (range, 2–7 days), with a mean blood loss of 40 mL per cycle. Menorrhagia is defined as blood loss of over 80 mL per cycle and frequently produces anemia. Metrorrhagia is defined as bleeding between periods. Polymenorrhea is defined as bleeding that occurs more often than every 21 days, and oligomenorrhea is defined as bleeding that occurs less frequently than every 35 days.
The International Federation of Gynecology and Obstetrics (FIGO) introduced the current classification system for abnormal uterine bleeding, and it was then endorsed by the American College of Obstetrics and Gynecology. The new classification system does not use the term “dysfunctional uterine bleeding.” Instead, it uses the term “abnormal uterine bleeding” (AUB) and pairs it with descriptive terms denoting the bleeding pattern (ie, heavy, light and menstrual, intermenstrual) and etiology (the acronym PALM-COEIN standing for Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not yet classified). In adolescents, AUB often occurs as a result of persistent anovulation due to the immaturity of the hypothalamic-pituitary-ovarian axis and represents normal physiology. Once regular menses has been established during adolescence, ovulatory dysfunction AUB (AUB-O) accounts for most cases. AUB in women aged 19–39 years is often a result of pregnancy, structural lesions, anovulatory cycles, use of hormonal contraception, or endometrial hyperplasia.
Signs and symptoms
The diagnosis depends on the following:
- A history of the duration and amount of flow, associated pain, and relationship to the last menstrual period (LMP), with the presence of blood clots or the degree of inconvenience caused by the bleeding serving as useful indicators;
- a history of pertinent illnesses, such as recent systemic infections, other significant physical or emotional stressors, such as thyroid disease or weight change;
- a history of medications (such as warfarin, heparin, or exogenous hormones) or herbal remedies that might cause AUB (such as ginkgo, motherwort and ginseng);
- a history of coagulation disorders in the patient or family members;
- a complete physical examination to evaluate for excessive weight and signs of polycystic ovary syndrome (PCOS), thyroid disease, insulin resistance, or bleeding disorder; and
- a pelvic examination to rule out vulvar, vaginal, or cervical lesions, pregnancy, uterine myomas, adnexal masses, adenomyosis, or infection.
A complete blood count, pregnancy test, and thyroid tests should be done. For adolescents with heavy menstrual bleeding and adults with a positive screening history, coagulation studies should be considered, since up to 18% of women with severe menorrhagia have an underlying coagulopathy. Vaginal or urine samples should be obtained for polymerase chain reaction (PCR) or culture to rule out Chlamydia infection. If indicated, cervical cytology should also be obtained.
Transvaginal ultrasound is useful to diagnose intrauterine or ectopic pregnancy or adnexal or uterine masses and to evaluate endometrial thickness. Sonohysterography or hysteroscopy may be used to diagnose endometrial polyps or subserous myomas. MRI is not a primary imaging modality for AUB but can more definitively diagnose submucous myomas and adenomyosis.
The purpose of endometrial sampling is to determine if hyperplasia or carcinoma is present. Polyps, endometrial hyperplasia and, occasionally, submucous myomas are identified on endometrial biopsy. Endometrial sampling should be performed in patients with AUB who are older than 45 years, or in younger patients with a history of unopposed estrogen exposure or failed medical management and persistent AUB. If the Papanicolaou smear abnormality requires it, or a gross cervical lesion is seen, colposcopic-directed biopsies and endocervical curettage are usually indicated